In-Training Exam High Yield Topics Toxicology ITE High Yield Topics Presentations: This is one of multiple presentations included in our revised 2018 EMF ITE resources. Presentation content is divided by system and includes the highest-yield (highest % on the test) systems: Cardiovascular, Trauma, Gastrointestinal, Pediatrics, Pulmonary, Toxicology, ID and Neurology. Each system presentation has three different sections: Visual Diagnosis, Clinical Concepts and Rapid Fire. Scattered throughout are “Knowledge Bomb” slides that provide a more in-depth summary of certain high-yield topics.   Timing: Each presentation in this series is of variable length, thus the time required to lead instruction will also be variable. In general, the expected time range for presentations is 30-60 minutes. The specific time you’ll need will depend not only on presentation length, but also how much embedded conversation or focused review (“knowledge bomb” content) you intend, in addition to the familiarity of your residents with this content. Emergency Medicine Foundations Curriculum

In-training Exam (ITE) Content: Written to level of EM3 Predicts performance on EM Boards 225 MC questions Given 4.5 hrs to take +/- 25 are visual stimuli – pictures/ekg/xrays Highest yield topics Cardiovascular ~ 10% Trauma ~ 10% Abd/GI ~ 8% Thoracic/Respiratory ~ 8% Procedures/Skills ~8% Note that Geriatrics makes up at least 6% of these and Pediatrics at least 8%

Foundations Challenge Overview Rapid Review of High-Yield Test Topics Visual Diagnosis Clinical Concepts Rapid Fire Work in 2-4 different teams Answer challenge questions for points Point value per challenge varies by difficulty Win test prep and pride Running the Meeting: Start by dividing learners into 2-4 teams and direct them to separate areas of the room You should assign a learner or instructor to serve as scorekeeper and ask for updates on the score when you switch topics Provide and guide reasonable time limits to answer challenge questions Monitor time closely as you move through the review to keep pace with planned content If you have the time/energy, you may consider giving a prize/reward for the winning team

Foundations Challenge Rules Create a Team Name Best Team Name starts the Challenge (as arbitrarily determined by your Instructor) Your team must answer the entire question correctly to win points If you team answers incorrectly, the Challenge Question points can be stolen by the next team If they answer correctly, they get your points AND a chance to answer the next question If they answer incorrectly, the turn passes again to the next team in line You may choose to modify the point assignment system (all or nothing vs partial credit)

toxicology

27 yo f non-responsive, barely breathing Foundations Challenge Visual Diagnosis 1pt 27 yo f non-responsive, barely breathing Dx and Tx?

27 yo f non-responsive, barely breathing Foundations Challenge Visual Diagnosis 1pt 27 yo f non-responsive, barely breathing Dx: Opioid Overdose Tx: Naloxone

HIV+ pt on Dapsone with fatigue, O2 sat 85% Foundations Challenge Visual Diagnosis 2 pts HIV+ pt on Dapsone with fatigue, O2 sat 85% Dx and Tx?

HIV+ pt on Dapsone with fatigue, o2 sat 85% 2 pts Foundations Challenge Visual Diagnosis HIV+ pt on Dapsone with fatigue, o2 sat 85% Dx: Methemoglobinemia Tx: Methylene blue

methemoglobinemia Knowledge Bomb Foundations Challenge What is it? Iron in Hgb gets oxidized to Fe3+ from normal Fe2+, causing impaired O2 binding and tissue hypoxia with methemoglobin levels >10% Causes Medications (dapsone, topical anesthetics, nitrites/nitrates, antimalarials, Pyridium), environmental (aniline dyes, well water) Diagnosis SaO2 ~85% (consistent with MetHgb >10%), “chocolate”-colored arterial blood, central cyanosis Treatment Methylene blue (reduces Fe3+ to Fe2+; N.B. avoid in G6PD deficiency, because this will cause hemolysis)

23 yo m with depression, brought in after suicide attempt 2 pts Foundations Challenge Visual Diagnosis 23 yo m with depression, brought in after suicide attempt Dx and Tx?

23 yo m with depression, brought in after suicide attempt Foundations Challenge Visual Diagnosis 2 pts 23 yo m with depression, brought in after suicide attempt Dx: TCA overdose Tx: sodium bicarb

TCA overdose Knowledge Bomb Foundations Challenge TCA overdose TCA Medications Amitriptyline, nortriptyline, doxepin Affects Basically all neuroreceptors (ACh -> anticholinergic ssx, NE -> alpha blockade, Na channel -> wide QRS, histamine, GABA -> seizures) Diagnosis No levels are available; consider for pt with depression, presenting with AMS, seizures, QRS widening, VT/VF Treatment Sodium bicarbonate (competes against Na channel blockade -> narrow QRS, decreased risk of VT/VF), otherwise supportive care only

How can you differentiate these toxidromes? Foundations Challenge Clinical Concepts 2 pts How can you differentiate these toxidromes? Serotonin syndrome Neuroleptic malignant syndrome

How can you differentiate these toxidromes? Foundations Challenge Clinical Concepts 2 pts How can you differentiate these toxidromes? Serotonin syndrome Neuroleptic malignant syndrome Both will be hyperthermic, likely agitated Clonus/hyperreflexia Muscle rigidity

How can you differentiate these toxidromes? Foundations Challenge Clinical Concepts 2 pts How can you differentiate these toxidromes? Anticholinergic Sympathomimetic

How can you differentiate these toxidromes? 2 pts Foundations Challenge Clinical Concepts How can you differentiate these toxidromes? Anticholinergic Sympathomimetic Both will be hyperthermic, although to a low degree, and both will likely be agitated (although anticholinergic toxidromes can also be obtunded or lethargic). Anticholinergic toxidrome: “Dry as a bone, hot as a hare, mad as a hatter, blind as a bat, red as a beet” Sympathomimetic toxidrome: Everything gets ramped up, causing a “fight or flight” physiologic response with mydriasis, tachycardia, agitation, and diaphoresis Dry (“as a bone”) Sweaty

Hot Tox (hyperthermic) toxidromes Foundations Challenge Knowledge Bomb Hot Tox (hyperthermic) Agitated Sedated Sympathomimetic (sweaty) PCP/cocaine (superhuman strength) Opioid (miosis) Anticholinergic (dry) Withdrawal syndromes (esp. EtOH) EtOH/benzos (no miosis) NMS (muscle rigidity) Cholinergic (wet, DUMBBELSS) Serotonin syndrome (clonus) Malignant hyperthermia (got succinylcholine)

When is activated charcoal contraindicated? Foundations Challenge Clinical Concepts 2 pts When is activated charcoal contraindicated? Name 1 When is activated charcoal ineffective? Name 1

When is activated charcoal contraindicated? 2 pts Foundations Challenge Clinical Concepts When is activated charcoal contraindicated? AMS/obtunded, Ileus, Vomiting, Risk of Seizure When is activated charcoal ineffective? Metals, Alcohols, Hydrocarbons, Caustics

Foundations Challenge Clinical Concepts 2 pts What is the classic metabolic disorder with salicylate toxicity? When do you dialyze for salicylate toxicity?

2 pts Foundations Challenge Clinical Concepts What is the classic metabolic disorder with salicylate toxicity? When do you dialyze for salicylate toxicity? Concurrent metabolic acidosis and respiratory alkalosis Acute: ASA>100mg/dL Chronic: ASA>60mg/dL OR Presence of renal failure, severe acidemia, cerebral/pulmonary edema

3 pts Associations Garlic smell, multi-organ failure Foundations Challenge RAPID FIRE 3 pts Associations Garlic smell, multi-organ failure Rotten eggs smell, unconscious pt On meds for TB, p/w seizure ???

3 pts Associations Garlic smell, multi-organ failure Foundations Challenge RAPID FIRE 3 pts Associations Garlic smell, multi-organ failure Rotten eggs smell, unconscious pt On meds for TB, p/w seizure Arsenic Hydrogen sulfide Isoniazid

2 pts Antidote time! Cyanide Methemoglobinemia ??? RAPID FIRE Foundations Challenge RAPID FIRE 2 pts Antidote time! Cyanide Methemoglobinemia ???

2 pts Antidote time! Cyanide Hydroxycobalamin OR Foundations Challenge RAPID FIRE 2 pts Antidote time! Cyanide Methemoglobinemia Hydroxycobalamin OR Na thiosulfate+Amyl nitrate+Na nitrate Methylene blue

3 pts Antidote time! Acetaminophen ??? Benzodiazepines Foundations Challenge RAPID FIRE 3 pts Antidote time! Acetaminophen Benzodiazepines Methanol/Ethylene Glycol ???

3 pts Antidote time! Acetaminophen N-acetylcysteine (NAC) Foundations Challenge RAPID FIRE 3 pts Antidote time! Acetaminophen Benzodiazepines Methanol/Ethylene Glycol N-acetylcysteine (NAC) Flumazenil (NB: may cause seizure) EtOH or fomepizole

Antidote time: toxidromes Foundations Challenge RAPID FIRE 5 pts Antidote time: toxidromes Sympathomimetic Anticholinergic Serotonin syndrome Neuroleptic malignant syndrome Malignant hyperthermia ???

Antidote time: toxidromes Foundations Challenge RAPID FIRE 5 pts Antidote time: toxidromes Sympathomimetic Anticholinergic Serotonin syndrome Neuroleptic malignant syndrome Malignant hyperthermia Benzos Benzos, consider physostigmine Benzos, consider cyproheptadine Benzos, consider bromocriptine Dantrolene

5 pts Antidote time: Metals Iron ??? Lead Mercury Arsenic Lithium Foundations Challenge RAPID FIRE 5 pts Antidote time: Metals Iron Lead Mercury Arsenic Lithium ???

5 pts Antidote time: Metals Iron Deferoxamine Lead Dimercaprol or EDTA Foundations Challenge RAPID FIRE 5 pts Antidote time: Metals Iron Lead Mercury Arsenic Lithium Deferoxamine Dimercaprol or EDTA Dimercaprol Hemodialysis

Good Luck!!! www.emergencymedicinefoundations.com

References Foundations Teaching Content: References: Dr. Andrew Ketterer, MD, MA Medical Education Fellow, Beth Israel Deaconess Dr. Kristen Grabow Moore, MD, MEd Assistant Professor, Emory University References: Life in the Fast Lane HippoEM Board Review Rivers Written Board Review Medscape emedicine Northwestern EM Chief Residents Author: Dr. Andrew Ketterer, Beth Israel Deaconess Medical Center Editor: Dr. Kristen Grabow Moore, Emory University   Content Revision 01 / 2018 References: Life in the Fast Lane HippoEM Board Review Rivers Written Board Review Medscape emedicine Northwestern EM Chief Residents